Ethical Dilemmas of Agency Nursing

[Sassy5d]

Hello All!

I'm an Ohio LPN who's been working agency for almost 3 years now. (Just 1 agency) What started as something I would be doing as I transitioned looking for a staff job, turned into my only job.

Along the way I've been really lucky to only have less then a handful of "problems" When I say problems, I mean, being so bad that I've had to call my employer and ask them to please never send me to "x" facility again.

The agency I work for is almost strickly nursing homes. I've never worked for a hospital and my only hospital "experience" was clinical.

The perks of Agency work for me has always been not getting involved with facility drama. You go in, do your job and then you go home. If you ever return to the place, great, if you don't, then you don't.

Here is my problem (I'm going to be as vague as possible. I do not want to give away any information which will connect any agency to any facility or to me either.)

I've been working at "x" facility for just about the entire time I've been employed with my agency. It was something I did occasionally since they only needed staff here and there. Changes occured with the management, and as expected, a ton of staff quit (or got fired) My agency was staffing this "x" facility almost 24 hours a day for months now. They only have about 5 regular staff.

They are not a regular facility as all the residents are completely private pay and they are not considered a nursing home.

When I would work 3rd shift.. I would be the only licensed person in the facility. They do not require their nursing assistants to be state tested. I was responsible for approx 45 people upstairs and about another 20-30 downstairs.

(I know this is getting long I'm going to cut it short now, I'm awaiting a call from my agency to find out if I'm going to be fired)

A resident that is on hospice.. He has cancer. He has a doctors order for two minor narcotics for pain. I talked to him almost nightly and he was always complaining of the inability to sleep. A doctor prescribed him a sleep aid. Hospice did not want him to have it. Even though there is an order, we are not to give it per hospice.

When I went to work Monday night, there was a note in the communication book from a staff nurse relaying info from the hospice nurse.

Hospice stated they wanted us to give him water instead of giving him his pain medication. (Not give him water and say it's his pain medication-rather-deny the man his pain medication and give him water instead) Hospice stated he's taking his pain medication for sleep.

I wrote a note in the communication notebook that the man specifically calls me and asks for "x" medication for his cough or "x" medication for his cancer pain. He does not call and say can I have "x" for sleep, nor does he ask just for a pain pill.

In hindsight, I can understand why my words were taken the way they were. One of the gals I work for told me on Tuesday that I completely offended the hospice nurse. The facility had called my boss to say I had no business writing in their communication book. Again, after it's been a few days, I do fully admit that I probably got carried away while I was upset.

Since writing in the book, and never having, in almost 3 years, a problem or complaint at that facility... They dnr'd me. My employee policy states getting a dnr is an automatic termination.

I understand what I did wrong. I should not have written in their notebook. Although I do stick by my feelings on the issue.

It just seems like an ethical dilemma. I'm sapposto be the patients advocate.. but I'm just an agency nurse, not a nurse for the facility..

Although doing what I did probably just cost me my job.. I'm coming here to ask you guys for the future... What do you do when a question of ethics comes up? Do you call your employer? Do you turn the other cheek? Do you call the heads of the facility you're working for?

Becky

[caliotter3]

The communication book's purpose is to communicate. It is your responsibility to use it if you have something to pass along to other staff. Keeping you from using this tool because you are "agency" is depriving you of a means of doing your job.

If someone wants to criticize you for what you put in there or how you stated something that is a different story. A verbal discussion is sufficient.

DNRing you b/c you used an avail tool to do your job, is wrong on the part of the facility. They are jumping the gun on this one. Bad decisions abound when everything is going bad. Otherwise their personnel would not be leaving and they would not be using agency to begin with.

If the agency that I worked for fired everyone for getting DNRd they would not be in business in my area. That is not to say that they act in their own best interests or the best interests of their employees either.

Your agency should back you up in this matter, but it most likely will not, and it is better not to go back there and face bad feelings anyway.

I do not agree that what you wrote was inappropriate for the communication book. I also do not agree w/what the hospice person gave instructions for. That is dishonesty and the pt deserves better. JMHO.

[Sassy5d]

I spoke with my boss. It's a conflict of personalities basically. I was not let go, but I was dnr'd. Apparently they just called and complained about the note and that was that, then they chose to interview their meager amount of staff and said they dnr'd me because of my attitude. I've always made it a point to never complain or talk down in front of any staff member so I have no idea what was said but that's besides the point.

Before the changes took place, it was a very pleasant place to work. Now with all the new changes it's pretty crazy. My boss told me had it just been the note they would not have dnr'd me, but what the staff had also said was what made the decision.

My boss agreed with what I wrote in the communication book, I openly admitted I went about it all wrong and my approach was not appropriate.(In a nutshell, some of my comments came off smart-ass-which again, I agree is not appropriate. We all learn from making mistakes. I know now in the future.)

Another reason why again, I liked agency work above staff jobs.. Generally you're not there long enough to let things get to you.. It's obviously a good thing that they don't want me back. I don't belong there. I'm just greatful that I did not lose my job.

I know now when a question of ethics comes up, to first call the call person at the facility, if that gets me nowhere, then I call my boss.

[caliotter3]

It sounds like your agency boss is reasonable, you are lucky in this respect. Not all agency mgmt will hear out their employees. Just chalk this situation up to lessons learned.

[Sassy5d]

I'm hoping it has something to do with me being an OK employee. I've never called off in 3 years except for this past tuesday when we were snowed in. I've gotten tons of praise from other facilities and only a time or two of complaints.

Substance abusing nurses working agency is a big problem in my area and I guess since I don't really cause them any problems, they are going to cut me a break. But, I know this is basically a second chance for me and I have to really think about my actions before I do them in the future. Which kinda stinks, having to "walk on eggshells" so to speak..

[Jolie, BSN]

I can't begin to understand why Hospice would insist on with-holding an ordered pain medication from a patient who is requesting it, nor do I understand why any professional nurse would blindly go along with such an inappropriate request.

I know that you don't want any more trouble, but this situation BEGS to be reported to the state ombudsman.

[caliotter3]

I reported more than once as required by law, and have been rewarded by unemployment. Employers prefer to turn a blind eye to infractions for which they have legal and moral responsibility, hoping that they can skate by. Employees are expendable. Mgmt will take action only to save their own employment. Skating around and getting rid of whistleblowers skillfully is considered success in the world of midlevel mgmt. Thus my comment, that it is fortunate the the OP got as much support from her boss as she did. The OP has her own survival to consider in the long run. Hope for the best.

[Sassy5d]

Jolie-I don't understand it either! I looked over his entire chart.. and his hospice nursing notes. I found one little comment about "Using pain meds for sleep" There was no-Pt stated using pain meds for sleep. It was just, using pain meds for sleep. To me, that's a big HELLO-The man asked for a sleeping pill, which the MD authorized and wrote a prescription for, and you don't want him to have his ambien. If he asked me for "X" and said "So I can sleep" or anything else other then specificially asking exactly what it was prescribed for.. I don't care if you work for hospice or not, you're a nurse just like everyone else. We have to follow doctors orders. If you feel that strongly about withholding prn's from a man, then contact the doctor and get an order. Gee, can't tick off hospice, but nobody really cares about ticking off the people who actually know the man and take care of him right? It's easy to tell people to do something, when you don't have to do it yourself. Let hospice come in at 11-12 at night and tell him all he can have is water.

[Sassy5d]

I guess it really doesn't matter at this point. The gentleman has an order for hycodan for his cough, vicodin for pain. He asks for his hycodan cough syrup for his cough, and his vicodin for his lung cancer pain (exact words) If he said Just cough syrup or pain, I would give him non-narcotic.. but he doesn't.

[LadyNASDAQ]

You should never take a problem like that into your own hands. You pass it off to your Recruiter and they decide what should be done.

The problem is this... you are not an employee. You are now thinking staff vs. agency. Your job is to do the job and go home. You are now getting into politics and shouldn't be involved with their problems and issues. Whatever the Hospice Nurse does, she is responsible for and it's possible the family has some input with what was ordered. Whatever happened, it's always a learned lesson and then you move on.

[nursejourney]

I too have just started working Agency (mostly nursing homes). It was mentioned to me the other day that "Agency" nurses shouldn't write in the communication book! What! How am I supposed to convey a message to someone if I can't write it in the appropriate resource. Oh well... it didn't stop me, and I mentioned it to the Director of Nursing in the Facility. She commented that I could write in the book, and that I was given false information.

Also, you should bare in mind that a Doctor's order is just that... an order. (Even if it is a prn). If the facility does not wish to give the medication, then this should be discussed with the Doctor. We have no right to deny a patient a medication which a doctor has rightfully prescribed.

The hospice patient has cancer.... I would hope that a sound palliative care approach is being followed. Good pain relief measures are essential, and are given for a purpose! What about beneficience, equity, and patient rights. Just because this person is not "a patient in a hospital" doesn't mean he should be treated differently.

I would like to congratulate you on being a caring nurse. Remember, one day it might be one of us laying there in pain.... do you want a nurse to give you water instead of pain relief? particularly if your doctor has already prescribed a pain relief med for you.

Patient advocacy is an essential part of the role of a nurse.

Nursejourney

[nursejourney]

Lesson learned... yes.... but another lesson is this: we are patient advocates (even for hospice residents). Just because we are Agency doesn't mean we stop being advocates.